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Appealing a health plan decision

Internal appeals

There are 3 steps in the internal appeals process:
  1. You file a claim: A claim is a request for coverage. You or a health care provider will usually file a claim to be reimbursed for the costs of treatment or services.
  2. Your health plan denies the claim: Your insurer must notify you in writing and explain why:
    • Within 15 days if youโ€™re seeking prior authorization for a treatment
    • Within 30 days for medical services already received
    • Within 72 hours for urgent care cases
  3. You file an internal appeal: To file an internal appeal, you need to:
    • Complete all forms required by your health insurer. Or you can write to your insurer with your name, claim number, and health insurance ID number.
    • Submit any additional information that you want the insurer to consider, such as a letter from the doctor.
    • The Consumer Assistance Program in your state can file an appeal for you.
You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. If you have an urgent health situation, you can ask for an external review at the same time as your internal appeal. If your insurance company still denies your claim, you can file for an external review.

What papers do I need?

Keep copies of all information related to your claim and the denial. This includes information your insurance company provides to you and information you provide to your insurance company like:
  • The Explanation of Benefits forms or letters showing what payment or services were denied
  • A copy of the request for an internal appeal that you sent to your insurance company
  • Any documents with additional information you sent to the insurance company (like a letter or other information from your doctor)
  • A copy of any letter or form youโ€™re required to sign, if you choose to have your doctor or anyone else file an appeal for you.
  • Notes and dates from any phone conversations you have with your insurance company or your doctor that relate to your appeal. Include the day, time, name, and title of the person you talked to and details about the conversation.
  • Keep your original documents and submit copies to your insurance company. Youโ€™ll need to send your insurance company the original request for an internal appeal and your request to have a third party (like your doctor) file your internal appeal for you. Make sure to you keep your own copies of these documents.

What kinds of denials can be appealed?

You can file an internal appeal if your health plan wonโ€™t provide or pay some or all of the cost for health care services you believe should be covered. The plan might issue a denial because:
  • The benefit isnโ€™t offered under your health plan
  • Your medical problem began before you joined the plan
  • You received health services from a health provider or facility that isnโ€™t in your planโ€™s approved network
  • The requested service or treatment is โ€œnot medically necessaryโ€
  • The requested service or treatment is an โ€œexperimentalโ€ or โ€œinvestigativeโ€ treatment
  • Youโ€™re no longer enrolled or eligible to be enrolled in the health plan
  • It is revoking or canceling your coverage going back to the date you enrolled because the insurance company claims that you gave false or incomplete information when you applied for coverage

How long does an internal appeal take?

  • Your internal appeal must be completed within 30 days if your appeal is for a service you havenโ€™t received yet.
  • Your internal appeals must be completed within 60 days if your appeal is for a service youโ€™ve already received.
  • At the end of the internal appeals process, your insurance company must provide you with a written decision. If your insurance company still denies you the service or payment for a service, you can ask for an external review. The insurance companyโ€™s final determination must tell you how to ask for an external review.

What if my care is urgent and I need a faster decision?

In urgent situations, you can request an external review even if you havenโ€™t completed all of the health planโ€™s internal appeals processes. You can file an expedited appeal if the timeline for the standard appeal process would seriously jeopardize your life or your ability to regain maximum function. You may file an internal appeal and an external review request at the same time.
A final decision about your appeal must come as quickly as your medical condition requires, and at least within 4 business days after your request is received. This final decision can be delivered verbally, but must be followed by a written notice within 48 hours.